Paper 3. the Health Visitor Contribution to the Parent/Health Visitor Relationship

Paper 3. The health visitor contribution to the parent/health visitor relationship.

Abstract: This paper, the third in a series of five, presents selected data from a qualitative study undertaken to identify measureable indicators of the parent/health visitor [HV] relationship. This paper focuses on the HV contribution to that relationship. Data from both HVs and parents reveal the importance of the HVs qualities, characteristics and their relational skills. These are discussed with reference to existing literature and research. (64 words)

Key words: Qualities, Relational skills, Qualitative research, Measurement indicators

Introduction

This is the third paper in a series of five, about research to develop an instrument to measure parent/HV relationships. It reports findings regarding HVs’ contributions to those relationships in terms of qualities, characteristics and relational skills, and discusses them in the context of published literature. Bidmead et al, (2015) reviewed measures used in non-health visiting, helping relationships and argued for a specific parent/HV relationship measure. Measures in other professions were developed on well-founded theories of helping relationships, to inform the selection of measurement indicators, so qualitative research was undertaken to further understand and develop a theoretical framework of parent/HV relationships. Bidmead et al (2016) reported findings about the parents’ contribution to parent/HV relationships from that study.

Methods

This qualitative research aimed to identify observable indicators and a theoretical framework for the planned instrument. Striving for an objective tool may appear to reduce the phenomenon of the parent/HV relationship in a way that detracts from the deeper meaning of ‘relationship’. However, the measure is not the relationship itself, simply and indicator of it. The methods were detailed in Bidmead et al, [2016]. In brief, stimulated recall interviews were carried out separately with each of the six health visitors/parent dyads recruited in a multicultural, deprived, urban community [Table 1]. The interviews were analysed thematically using NVivo [QSR version 8]. The analysis was confirmed in discussion with one group of HVs [n=7] and one of parents [n=3].

Further analysis revealed rich data about the HV contribution [qualities, characteristics and relational skills] to the relationship with parents, reported below.

[Insert Table 1 here]

Qualities and Characteristics

Nine qualities and characteristics, described below, were identified by HVs and parents in this study. Table 2 summarises similarities and differences in emphasis and terminology between the two groups and in previous literature.

[Insert Table 2 about here.]

Parents valued HVs technical knowledge, recognising it as evidence-based. HVs too valued this knowledge as part of their professional role.

[HV4]…. She'd obviously been having some discussions with them [family] and often that is a topic [weaning] where clients have had input from family and friends but we're [HVs] able to bring more recent and up-to-date, research-based advice and so…… That’s an example of where I’d see health visiting being different because of that evidence-based knowledge.

Sound advice given by an experienced, knowledgeable HV, helped to build trust and strengthen the relationship.

Empathy also seemed central, although only one HV actually named it as an important quality. Others showed it whilst discussing and explaining parent’s concerns and difficulties, demonstrating it by their facial expressions and words they used. This was important in terms of identifying observable indicators.

Empathy involves ‘trying to understand’ (Davis et al, 2002), which may be particularly difficult if parents are from other cultures or their first language is not English. Whilst the effort of trying to understand may suffice for relationship building, this element was only identified in the HV data. Parents may have been unaware that HV’s struggled at times.

Parents greatly appreciated HV’s empathy, calling it ‘understanding’, and finding it a relief to talk because they felt understood.

HV availability by telephone was important to parents and HVs especially during relationship development when parents were less confident. Parents with questions particularly appreciated feeling comfortable enough to phone in so HVs had to be approachable.

[P4] She's gave me her phone number so I could speak to her if I've got any questions, I could phone her up and that, which is good because I do feel like I could actually phone her.

HVs felt they needed to be honest with parents about the organisational constraints affecting their relationships. One HV was careful to explain to parents that they would not see her at the clinic that they attended.

One Parent wanted a relationship with the HV where she could be ‘brutally honest [P1]’; that the HV was outside her normal circle of family and friends made this possible allowing her to explain when she disagreed with HV advice.

Parents seemed sensitive to the genuineness of HVs concern and appreciated that HVs seemed ‘genuinely interested’ in them and their babies.

Respect is complex (see Table 2) but for HVs and parents in this study it incorporated a non-judgemental attitude, interest in the parent, politeness, praise, punctuality and flexibility of approach.

A non-judgemental attitude differentiated HVs from friends and family enabling, parents to feel comfortable enough to express their needs. One parent reported that with her first child she had post-natal depression but she was unable to reveal it. With the second child the HV’s non-judgemental approach was crucial to obtaining the necessary support.

[P4] ….it’s important that you don't feel like you're being judged and that they're there to help you rather than them to criticise, which is really good.

HVs demonstrated respect when they were interested in parents and their families, not just the baby, helping raise parents’ self-esteem.

HVs respected parents for the struggles they had to face, their views and opinions. For example, when visiting a postnatally depressed, mother [P5] struggling with social isolation and visa problems, the HV expressed her admiration of her ability to care for her son so well.

Although parents did not speak about the HV respecting them, one parent spoke of the HV’s politeness as affecting her ability to be open. Where HVs failed to introduce themselves and there were punctuality difficulties, for example, there was potential for relationship break-down.

On the other hand, HVs demonstrated respect by being reliable, returning phone messages and doing what they said they would, aiming to build trusting relationships.

[HV 3] Any time she's made calls or left messages for me to contact her I've always followed things up; ….. whatever is necessary for her and see that through and that way, you know, shows reliability so then she knows that she can trust me. I think that if you let her down by not following on, that would have an effect on the relationship.

The HVs tried to be flexible about arrangements for home visiting, for the parents’ convenience. They used professional judgment about levels of support needed in spite of organisational constraints about the number of visits to deliver in an area of deprivation. They also demonstrated flexibility when advice giving, affirming parents’ decisions unless there might be adverse effects on the child.

When HVs praised parents for their child care, parents felt respected, building their confidence, feeling that the HV trusted them with their child.

HVs felt the ability to trust the parent was important to the relationship, which parents were also aware of.

[HV2] Well, I suppose, because I felt she was taking on board what I was saying I knew she would come back, I knew she wouldn't just drop out of the system so ‘cause that's another thing I'm always thinking about. Can I trust this person to come to the baby clinic and get the six weeks check done and the immunisations? So there's trusting in there.

HVs also spoke of distrusting some parents, particularly those with mental health or child protection issues. They realized that distrust could potentially damage their relationship, causing difficulties. For example, knowing that the HV distrusted her, one mother avoided her by attending different clinics and the father was aggressive towards the HV at home visits, making it very hard to continue to offer a service.

A calm, gentle approach seemed to relax parents enabling them to speak easily of their difficulties and unafraid to express their concerns.

[P1] And I don’t think anything would faze her and she’s just completely calm and that whole kind of personality just makes me think that it’s ok I can say anything. I think it’s her manner as well she’s really kind of gentle.

Parents identified caring as essential quality in the relationship.

[P6] She obviously takes good care of you and the situation you're in.

HVs caring for the parent and the parent’s whole situation might include other family members, and the amount of social support available through friendships or local community groups.

HVs demonstrated their care of parents, speaking about their motivation to help them in any way that they could, for example by listening to the parent’s story and showing they felt a need to provide solutions to difficult situations.

[HV1] I really wanted to do something for her to sort of sort this baby who was crying a lot …I wanted to help her in some way. I wanted to do something positive for her that she could go away with today that would help her through the next week.

Parents wanted HVs to be ‘friendly’ towards them.

[P4] I think it’s just that she's friendly as well which is nice like, cause you can get some people that come and they’re just doing their job and they’re not really there for any other reason .... But I feel that she was trying to make you feel better…

HVs, likewise, spoke about trying to make themselves ‘approachable’ so parents would contact them if they needed help.

Qualities and characteristics: Discussion

Many of the nine qualities or characteristics identified by HVs and parents as important to their relationships were found in the literature but some were not or appeared in novel guise in this study. The HVs’ calmness and gentleness were deemed important, as were their friendliness, sense of humour and trust in parents. Also, most literature about building trust in relationships refers to the client’s trust in the helper rather than the other way round. This study showed mutual trust in interactions when there were good relationships between HVs and parents.

A concept analysis of partnership working in health visiting (Bidmead and Cowley 2005) drew attention to the qualities of respect, genuineness, humility or acknowledgement of personal limitations, warmth, quiet enthusiasm, empathy, friendliness and approachability. Most of these were confirmed by this present study with the exception of humility and warmth.

HVs’ knowledge and experience were the overriding characteristics that parents highly valued (Russell and Drennan 2007). Confirming previous research findings, this knowledge was both experiential and professional (Collinson and Cowley, 1998; Plews et al, 2005) and parents felt it was unavailable to them elsewhere.

HVs’ respect for parents was demonstrated by being punctual, trying to arrange visits at the parent’s convenience, being polite, praising and encouraging parent decision-making. However, being non-judgemental was the essence of respecting parents as identified in previous research (Normandale, 2001; McIntosh and Shute, 2006). In a study of Canadian public health nurses, many mothers were ambivalent about receiving home visits, fearing being judged as failing or inadequate (Jack et al, 2005). Similarly, in the Oxford intensive home visiting study parents thought HVs were only there to check ‘you are keeping your kid properly fed’ (Kirkpatrick et al, 2007).

Support for parent decision-making was also a critical factor in demonstrating respect, reflecting previous research findings in building parental confidence through empowerment (McNaughton, 2000). Being respectful of parental autonomy and control needs, politeness, praising them and arranging visits according to parental convenience have been identified as being instrumental in gaining access to parents (Luker and Chalmers, 1990).

Reliability was an important factor in the development of parental trust (Jack et al 2005). The HVs demonstrated this by returning telephone calls, by being available should problems arise, by the HV’s flexibility to home visit when necessary, being non-judgemental, giving sound effective advice and continuity of contact. The importance of trust in a relationship has been explored in health visiting literature but there has been little written about HVs’ abilities to trust parents.

HVs’ abilities to trust parents and be friendly could possibly be coloured by their constructs and stereotypes when faced with a particular kind of parent. Previous experiences of encounters with teenage mothers, for example, may replay in their minds and unconsciously influence not only the relationship but also the service offer made (Chalmers, 1992). In this study HVs were aware of this possibility and endeavoured to avoid stereotypical approaches.

When parents experienced HVs as interested not only in babies but also in themselves, they reported feeling respected, important and their self-esteem grew. Kirkpatrick et al (2007) also found this led to the building of positive relationships.

Gentle, caring HVs enabled parents to speak freely. Pearson (1991) also found such an approach useful during the early months of parenting. As time progressed and mothers became more confident, then HVs withdrew. The majority of parents in this study were in early parenthood and had experienced the HV as caring. This caring approach was also found by Cowley (1991) as crucial to the ‘opening up’ of otherwise ‘closed’ conversations.

The HV needed to be honest and genuine in family interactions, demonstrating interest and caring, adopting a non-judgemental attitude, enabling parents to confide in her. Parents learnt to trust the HV and the relationship was enhanced where HVs could trust parents, although this may not always be possible. Their friendly approach and calmness, empathy and understanding were all qualities that parents greatly appreciated.

Relational skills

Helper qualities and characteristics can be demonstrated through a large set of relational skills, which have been described in the helping literature generally (Carkhuff, 2000; Davis and Day, 2010; Egan, 1998; Rogers, 1959). [Table 3]

[Insert Table 3 about here]

Listening was the most valued skill for both HVs and parents considered crucial for helping.

[HV1] It was the listening that was helping her and that maybe not advising her on every single thing that she was saying, I think, to let her continue to talk as long as she wanted to really.